What Is RA?

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Rheumatoid arthritis, or RA, is a systemic inflammatory disease that causes pain, stiffness, swelling and loss of motion in the joints. It is an autoimmune disease in which, for unknown reasons, the immune system turns against body's own tissue. In RA, the immune system attacks the tissue that lines the joints, called the synovium, causing inflammation that can eventually destroy the synovium and the joint.

Some people have mild or moderate forms of rheumatoid arthritis with only occasional symptoms while others have a severe form of the disease that can cause progressive joint damage and disability.

RA can start in any joint, but it most commonly begins in the smaller joints of the fingers, hands and wrists. Other joints that are commonly affected include hips, knees, ankles, feet, neck, shoulders and elbows. Joint involvement is usually symmetrical, affecting both sides of the body equally. In addition to joint pain and inflammation, people with RA may have fatigue, occasional fevers and a general sense of not feeling well.

Although there is no cure for RA, studies have shown that early and aggressive treatment can limit joint damage, thus improving joint function, mobility and quality of life for patients.

How a Healthy Joint Works

A joint is a place where two bones meet. Most joints in the body allow a great deal of movement between the bones. Inside these joints, cartilage covers the ends of the bones, cushioning them from one another. The joint itself is lined with a thin tissue called the synovial membrane. This tissue produces a substance called synovial fluid that lubricates and nourishes the cartilage, ligaments and bones in the joint cavity.

Under normal circumstances, a joint allows a smooth, guiding movement of bone upon bone. The cartilage provides a smooth surface and the synovial fluid provides just the right amount of lubrication for easy movements to take place through a full range of motion.

From Healthy Joint to Damaged Joint

In rheumatoid arthritis, the body's immune system attacks the cells of the synovium. This attack inflames the joint, making it red, warm and painful. During periods of inflammation, the cells of the synovium abnormally increase in number. This increased cell growth thickens the synovium, and that leads to more joint swelling.

As the disease progresses, the abnormal synovial cells invade and destroy the cartilage and bone inside the joint. Eventually, the muscles, ligaments and tendons that support the joint weaken. In severe cases, bones may eventually fuse together as the joint erodes away. All of this contributes to pain, loss of function and, in some cases, deformities at the affected joint.

If rheumatoid arthritis is left untreated, it can cause permanent damage to bones and tissues and cause the bones to shift out of alignment, which can make even simple tasks such as writing difficult.

Because joint damage can get worse, even when pain and swelling are relieved, it's important to treat the cause of this joint damage and not just control pain.

Close-Up of the Progression of RA Joint Damage

The joint pain and inflammation of RA begins when white blood cells (part of the immune system that cause inflammation) accumulate in the synovial tissue. The white blood cells produce substances called cytokines that transmit messages between different cells. In healthy cells, cytokines cause inflammation in response to infection. Researchers believe that in RA several cytokines (including one called TNF, or tumor necrosis factor) may be overproduced thus contributing to ongoing inflammation and destruction of cartilage, bone and other joint tissues.

Specific Joints' Problems in Untreated RA

If not treated, RA can cause significant joint destruction and deformity. Some of the specific joint issues that may also occur as the disease progresses include the following:

Hands and wrists

Ulnar drift: swelling of the joints, which moves tendons and ligaments out of position and causes the fingers to bend toward the little finger

Swan-neck deformities: changes in the tissues around finger joints, which result in abnormal bending and straightening of the fingers

Mallet finger: a deformity in which the fingertip is curled in and cannot straighten itself.

Tendon loosening or ruptures: caused by inflammation in the joints

Movement issues: inability to bend the wrist up or down due to inflammation

Locked or catching joints: deformities or rheumatoid nodules that cause the fingers to lock in unusual positions as the person tries to bend them

Feet

Hammer toes: changes in the tissues around the toe joints that cause abnormal bending of the toes

Bunions: changes in the tissues around joints of the big toe that cause it to bend toward the little toe and develop a bony nodule

Pes planus: loosening of the arch joint in the middle of the foot , which causes a painful flat foot

Valgus hind foot: loosening of the joint below the ankle, which causes the foot to bend outward

Walking problems: caused by pain in the toes and other deformities

Neck

Joint damage can limit neck movement from side to side or up and down and cause neck stiffness, weakness and loss of motion.

Shoulders

Decreased range of motion in the shoulder joint that often makes daily tasks, such as reaching or lifting, difficult and painful.

Knees

Inflammation: if not controlled by treatment, can cause erosion of cartilage and eventually lead to the need for knee replacement surgery

Baker's cyst: a fluid-filled lump that appears behind the knee

Preventing Joint Damage by Treating RA Early

Until recently, doctors treated rheumatoid arthritis first with pain relievers, rest and physical therapy and turned to more powerful drugs only if the disease worsened. Now many doctors believe early treatment with more powerful drugs, often used in combination, may curtail the progression of rheumatoid arthritis and slow or even stop damage to the joints. Some of the common medications prescribed for RA patients include:

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a class of drugs including aspirin, ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn) that are used to reduce pain and inflammation and may be used for both short-term and long-term relief in people with rheumatoid arthritis. Prescription NSAIDs include the newer drugs known as the COX-2 inhibitors like Celebrex (celecoxib) that block an enzyme known to cause an inflammatory response.

Steroids are used to combat inflammation and to suppress immune response. They work quickly and dramatically but also cause many side effects. Steroids can be taken by mouth or given by injection. Patients using steroids should be carefully monitored by their doctors. Some common steroids are prednisone (Deltasone, Orasone), methylprednisolone (Medrol), cortisone (Cortone Acetate) and hydrocortisone (Cortef, Hydrocortone).

Disease-modifying anti-rheumatic drugs (DMARDs) slow the progression of rheumatoid arthritis and prevent the destruction of cartilage and joints. DMARDs work by interfering with or depressing the immune system and are used throughout the course of the disease. It usually takes a few weeks or even months for DMARDs to have an effect, and patients may eventually use several different products. Patients taking DMARDs should be monitored carefully by their doctors. Examples of DMARDs include injectaible or oral gold, hydroxychloroquine (Plaquenil), penicillamine (Cuprimine, Depen), sulfasalazine (Azulifidine), methotrexate (Rheumatrex), azathioprine (Imuran), cyclosporine (Sandimmune, Neoral) and leflunomide (Arava).

How Biologic Medications Help Control RA Joint Damage

In addition to the NSAIDs, steroids and DMARDs, there are now therapies available that address not only the signs and symptoms of RA, but also help prevent further joint damage. Biologic therapies (biologics) are newer drugs used for the treatment of rheumatoid arthritis that reduce inflammation in the joints by blocking the action of specific inflammatory proteins (e.g., TNF or IL-1) or cells (e.g., T cells or B cells). Currently available biologic therapies must either be injected under the skin (Enbrel, Humira, Kineret) or infused through an IV (Remicade, Orencia and Rituxan).

Other Ways to Control RA Pain and Avoid Joint Damage

Because treatment for rheumatoid arthritis is improving, it is possible to gain control of RA and prevent extensive joint damage. Things you can do to manage your RA include:

Get early, aggressive treatment and have regular checkups. Studies have shown that RA patients who are treated early and see their rheumatologist several times a year have less joint damage than those who do not.

Exercise regularly. Your doctor or physical therapist can help you find exercises you can safely do to make your joints stronger.

Balance rest with activity. Finding the right mix of rest and exercise will help you control fatigue and reduces the likelihood of aggravating inflamed joints.

Perform relaxation exercises. Although stress does not cause rheumatoid arthritis, it can make this condition more difficult to manage and may even increase the amount of pain you feel.

Get support from friends and family. While it may be difficult to ask for help, research shows that a strong support system can actually help improve RA symptoms.

Get enough sleep. Research suggests that a lack of sleep and rheumatoid arthritis pain are tightly linked. RA patients who don't get enough sleep or have poor sleep quality report more fatigue and moodiness, as well as increased pain and stress.

For more on rheumatoid arthritis pain control and treatment, check out these HealthTalk resources:

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